Seven legal barriers to end-of-life care: myths, realities, and grains of truth

Do-Not-Attempt-Resuscitation Orders in Older Adult Patients With Out-of-Hospital Cardiac Arrest: A Single-Center Retrospective Study at an Urban University Hospital Emergency Department in Japan

Introduction Despite its super-aging society, advance directives or physician orders for life-sustaining treatment are uncommon in Japan. This study aimed to determine the incidence of do-not-attempt-resuscitation (DNAR) orders in older adult patients with out-of-hospital cardiac arrest in Japan and whether cardiopulmonary resuscitation was canceled based on these orders. Methods We retrospectively analyzed patients with out-of-hospital cardiac arrest aged ≥65 years who were transported to and treated at Keio University Hospital emergency department between January 1, 2016, and December 31, 2018. Patients with in-hospital cardiac arrest, those treated by clinical departments other than the emergency department, and those transported from other hospitals were not included. We assessed the rate of DNAR orders and cardiopulmonary resuscitation terminations in patients in the emergency department with DNAR orders. Results Among the 142 included patients, 23 (16%) had not attempted resuscitation orders made by the patients or family members. Of these, six (26%) underwent continued cardiopulmonary resuscitation despite their DNAR orders. The reasons for continuing cardiopulmonary resuscitation were delays in confirming the DNAR orders and problems in understanding the DNAR orders. Patients of higher age, male sex, nursing home admission, and continued medical examination at our hospital were significantly more likely to desire DNAR orders. Conclusions In Japan, the number of DNAR orders among older adults is low. Furthermore, these orders are not sufficiently understood, even by medical workers. Thus, increased medical and social awareness of advance directives and physician orders for life-sustaining treatment is needed.

The Emotions in Bioethical Decision-making

In an era of evidence-based medicine and an increasing use of technology the question is raised again as to what extent emotions should play in medical and ethical decision-making. While clearly the correct facts in each case are a sine qua non for ethical decision-making, and one should evaluate each situation rationally in accord with accepted ethical principles, the appropriate role of the emotions in decision-making is gaining increased attention in part as a result of newer research in neuroethics. In end-of-life care there often exists a disconnect between the "rational" analysis by many philosophers and ethicists and the emotional reactions of many physicians and nurses with respect to the comparison between withholding and withdrawal of life-sustaining therapy. It is suggested that these attitudes of many health care workers should not be ignored because they represent a critical, almost universal, and laudable value of reluctance to take human life, a value so strongly ingrained in the ethos of the medical profession.

Use of antimicrobial agents in actively dying inpatients after suspension of life-sustaining treatments: Suggestion for antimicrobial stewardship

BACKGROUND

The role of antimicrobial treatment in end-of-life care has been controversial, whether antibiotics have beneficial effects on comfort and prolonged survival or long-term harmful effects on increasing antimicrobial resistance. We assessed the use of antimicrobial agents and factors associated with de-escalation in inpatients who suspended life-sustaining treatments (SLST) and immediately died.

METHODS

We included 1296 (74.7%) inpatients who died within 7 days after SLST out of 1734 patients who consented to SLST on their own or family's initiative following a decision by two physicians, observing the "Life-sustaining Treatment Decision Act" between January 2020 and December 2020 at two teaching hospitals. De-escalation was defined as changing to narrower spectrum anti-bacterial drugs or stopping ≥ one antibiotic of combined treatment.

RESULTS

90.6% of total patients received anti-bacterial agents, particularly a combination treatment in 60.1% and use of ≥ three drugs in 18.2% of them. Antifungal and antiviral drugs were administered to 12.6% and 3.3% of the patients on SLST, respectively. Antibacterial and antifungal agents were withdrawn in only 8.3% and 1.3% of the patients after SLST, respectively. Anti-bacterial de-escalation was performed in 17.0% of patients, but 43.6% of them received more or broad-spectrum antibiotics after SLST. In multivariate regression, longer hospital stays before SLST, initiation of SLST in the intensive care unit, and cardiovascular diseases were independently associated with anti-bacterial de-escalation after SLST.

CONCLUSIONS

The intervention for substantial antibiotic use in patients on SLST should be carefully considered as antimicrobial stewardship after decision by the will of the patient and proxy.

Aggressive End-of-Life Care and Symptom Relief Treatments in Terminally Ill Patients Who Had Discussed Withdrawal of Mechanical Ventilation: A Hospital-Based Observational Study

OBJECTIVE

The aim of this study was to explore the status of aggressive end-of-life care and symptom relief treatments in terminally ill patients who had discussed the withdrawal of mechanical ventilation.

METHODS

This research is a retrospective observational study based on a chart review. Terminal patients aged ≥20 years, who were intubated with mechanical ventilation support, who underwent hospice-shared care, and who personally, or whose close relatives, had discussed the withdrawal of mechanical ventilation with hospice-shared care team members in a tertiary hospital in Taiwan during 2012 to 2015 were included. Demographics, medical conditions, and aggressive end-of-life care, including hospitalization, use of vasopressors, artificial nutrition, tube feeding, antibiotics, and symptom relief treatments including the use of opioids, steroids, and sedatives, were identified. The modes of care and treatments of patients by the status of withdrawal of mechanical ventilation were compared.

RESULTS

A total of 141 patients had discussed the withdrawal of mechanical ventilation, and 111 (78.7%) had been withdrawn. Aggressive end-of-life care was noted in all patients regardless of mechanical ventilation status. There were no significant differences in the number and pattern of aggressive end-of-life care measures between patients who had or had not been withdrawn. There were significantly higher rates of symptom relief treatments used in patients who had been withdrawn.

CONCLUSIONS

Aggressive end-of-life care is common for patients who have discussed the withdrawal of mechanical ventilation. There are significantly higher rates of symptom relief medications administered in patients who have been withdrawn from mechanical ventilation.

Nurses' Experiences and Factors Related to Their Attitudes Regarding Discussions with Patients and Family Members about Do-Not-Resuscitate Decisions and Life-Sustaining Treatment Withdrawal: A Hospital-Based Cross-Sectional Study

This study aimed to evaluate nurses’ experiences and factors related to their attitudes regarding discussions of do-not-resuscitate (DNR) and withdrawal of life-sustaining treatment (LST) with patients and their families. A cross-sectional survey was conducted in a tertiary hospital in Taiwan. Nurses aged ≥ 20 years who were in charge of acute inpatient care were randomly recruited. A semi-structured questionnaire was used to evaluate participants’ experiences and attitudes regarding discussions of DNR and LST withdrawal for terminal patients. Logistic regression with adjustment for covariates was used to analyze factors related to participants’ attitudes toward discussions about DNR and LST withdrawal with patients and families in the future care of terminal patients. The participants were 132 nurses. They had significantly more discussions about DNR and LST withdrawal with patients’ families than with patients. Regression analysis showed that participants who had past experiences in actively initiating DNR discussions with patients or patients’ families were significantly more likely to discuss DNR with patients in the future care of terminal patients, but participants aged 40.0 to 60.0 years were significantly less likely to have DNR discussions than those aged 20.0 to 29.9 years. Experiences of actively initiated DNR or LST discussions with patients’ families were significantly more likely to discuss DNR with patients’ families, but those aged 40.0 to 60.0 years were also significantly less likely to have DNR discussions than those aged 20.0 to 29.9 years. Experience in actively initiating discussions about LST withdrawal with patients’ families, being male, and possessing an education level higher than university were significantly related to LST withdrawal discussions with terminal patients or their families in the future. In conclusion, there need to be more discussions about DNR and LST withdrawal with patients. To protect patients’ autonomy and their rights to make decisions about their DNR and LST, measures are needed to facilitate DNR and LST discussions with patients to ensure better end-of-life care.

Top-cited articles in medical professionalism: a bibliometric analysis versus altmetric scores

INTRODUCTION

Citation counts of articles have been used to measure scientific outcomes and assess suitability for grant applications. However, citation counts are not without limitations. With the rise of social media, altmetric scores may provide an alternative assessment tool.

OBJECTIVES

The aims of the study were to assess the characteristics of highly cited articles in medical professionalism and their altmetric scores.

METHODS

The Web of Science was searched for top-cited articles in medical professionalism, and the characteristics of each article were identified. The altmetric database was searched to identify report for each identified article. A model to assess the relationship between the number of citations and each of the key characteristics as well as altmetric scores was developed.

RESULTS

No correlations were found between the number of citations and number of years since publication (p=0.192), number of institutes (p=0.081), number of authors (p=0.270), females in authorship (p=0.150) or number of grants (p=0.384). The altmetric scores varied from 0 to 155, total=806, median=5.0, (IQR=20). Twitter (54%) and Mendeley (62%) were the most popular altmetric resources. No correlation was found between the number of citations and the altmetric scores (p=0.661). However, a correlation was found for articles published in 2007 and after (n=17, p=0.023). To further assess these variables, a model was developed using multivariate analysis; did not show significant differences across subgroups. The topics covered were learning and teaching professionalism, curriculum issues, professional and unprofessional behaviour.

CONCLUSIONS

Altmetric scores of articles were significantly correlated with citations counts for articles published in 2007 and after. Highly cited articles were produced mainly by the USA, Canada and the UK. The study reflects the emerging role of social media in research dissemination. Future studies should investigate the specific features of highly cited articles and factors reinforcing distribution of research data among scholars and non-scholars.

Management of patients with an advance decision and suicidal behaviour: a systematic review

BACKGROUND

The use of advance care planning and advance decisions for psychiatric care is growing. However, there is limited guidance on clinical management when a patient presents with suicidal behaviour and an advance decision and no systematic reviews of the extant literature.

OBJECTIVES

To synthesise existing literature on the management of advance decisions and suicidal behaviour.

DESIGN

A systematic search of seven bibliographic databases was conducted to identify studies relating to advance decisions and suicidal behaviour. Studies on terminal illness or end-of-life care were excluded to focus on the use of advance decisions in the context of suicidal behaviour. A textual synthesis of data was conducted, and themes were identified by using an adapted thematic framework analysis approach.

RESULTS

Overall 634 articles were identified, of which 35 were retained for full text screening. Fifteen relevant articles were identified following screening. Those articles pertained to actual clinical cases or fictional scenarios. Clinical practice and rationale for management decisions varied. Five themes were identified: (1) tension between patient autonomy and protecting a vulnerable person, (2) appropriateness of advance decisions for suicidal behaviour, (3) uncertainty about the application of legislation, (4) the length of time needed to consider all the evidence versus rapid decision-making for treatment and (5) importance of seeking support and sharing decision-making.

CONCLUSIONS

Advance decisions present particular challenges for clinicians when associated with suicidal behaviour. Recommendations for practice and supervision for clinicians may help to reduce the variation in clinical practice.

Regulating advance decision-making: potential and challenges for Malaysia

The right to refuse treatment is generally accepted in the legal and bioethics discourses; however, the use of advance directives remains contentious. Some jurisdictions have introduced statutory frameworks to govern the creation and implementation of advance directives, underpinned primarily by the recognition of respect for personal autonomy. Although there are no legislation and judicial decisions on advance decision-making in Malaysia, the considered view is that healthcare practitioners perceived its utility in managing patient care. This paper examines the potential and challenges of applying a statutory framework in Malaysia, drawing from relevant regulatory examples. It argues for greater public awareness within the healthcare discourse and knowledge dissemination regarding the availability, usage and clinical guidance on advance decision-making. The main conclusion drawn from this exploratory analysis is that further understanding of and education about advance decision-making within the population and healthcare practitioners should precede the implementation of a statutory regime in Malaysia.

One Ventilator Too Few?

Sometimes it's better to be lucky than good. As new blood filled our young patient's veins, her breathing became regular and her pulse full. She was so far gone I would not have expected her to recover consciousness for a day, if at all, but within an hour, she began to wake up. We removed the breathing tube a couple of hours later- no ventilator ever needed. As life-sustaining technology becomes more widely available in fortunate parts of the developing world, benefits come with complications. The temptation is to focus on the thing-the ventilator itself-as the crucial element and press to buy more, mistaking the problem for one of resource scarcity only. But we need a culturally relevant ethical framework to guide the use and withdrawal of ventilators and similar life-sustaining tools. Resource scarcity is only part of the problem. Buying additional ventilators only defers allocation decisions and entirely fails to address end-of-life suffering. It is unsustainable in Rwanda; it is a dubious solution anywhere. The intangible need for an ethical framework hides beneath apparent scarcity and, when this need is not addressed and luck runs out, one salvageable patient can die for want of a ventilator that serves only to prolong the suffering of another.

The Voice Is As Mighty As the Pen: Integrating Conversations into Advance Care Planning

Advance care planning allows patients to articulate preferences for their medical treatment, lifestyle, and surrogate decision-makers in order to anticipate and mitigate their potential loss of decision-making capacity. Written advance directives are often emphasized in this regard. While these directives contain important information, there are several barriers to consider: veracity and accuracy of surrogate decision-makers in making choices consistent with the substituted judgement standard, state-to-state variability in regulations, literacy issues, lack of access to legal resources, lack of understanding of medical options, and cultural disparities. Given these issues, it is vital to increase the use of patient and healthcare provider conversations as an advance care planning tool and to increase integration of such discourse into advance care planning policy as adjuncts and complements to written advance directives. This paper reviews current legislation about written advance directives and dissects how documentation of spoken interactions might be integrated and considered. We discuss specific institutional policy changes required to facilitate implementation. Finally, we explore the ethical issues surrounding the increased usage and recognition of clinician-patient conversations in advance care planning.

Ethical and end of life considerations for neonates requiring ECMO support

ECMO has proven to be a life-saving intervention for a variety of disease entities with a high rate of survival in the neonatal population. However, ECMO requires clinical teams to engage in many ethical considerations. Even with ongoing improvements in technology and expertise, some patients will not survive a course of ECMO. An unsuccessful course of ECMO can be difficult to accept and cause a great deal of angst. These questions can result in real conflict both within the care team, and between the care team and the family. Herein we explore a range of ethical considerations that may be encountered when caring for a patient on ECMO, with a particular focus on those courses where it appears likely that the patient will not survive. We then consider how a palliative care approach may provide a tool set to help engage the team and family in confronting the difficult decision to discontinue ECMO.

Advance Directive in End of Life Decision-Making among the Yoruba of South-Western Nigeria

End-of-life decision making is value-laden within the context of culture and bioethics. Also, ethics committee role is difficult to understand on this, thus need for ethnomethodological perspective in an expanding bioethical age. Anthropological approach was utilized to document Yoruba definition and perspective of death, cultural beliefs about end-of-life decision making, factors influencing it and ethics committee role. Interviews were conducted among selected Yoruba resident in Akinyele LGA, Oyo State, Nigeria. Content analytical approach was used for data analysis. Yoruba culture, death is socially constructed having spiritual, physical and social significance. Relationship between the dying and significant others influences decision making. Hierarchy of authority informs implementing traditional advance directive. Socialization, gender, patriarchy, religious belief and tradition are major considerations in end-of-life decision making. Awareness, resource allocation and advocacy are important ethics committees' roles. Further research into cultural diversity of end-of-life decision making will strengthen ethical practice in health care delivery.

Clinical Issues and Controversies in Heart Failure and Transplantation

Heart failure is a common problem among children admitted in the intensive care unit and is associated with significant morbidity and mortality. As such, the 2014 meeting of the Pediatric Cardiac Intensive Care Society included a session on Clinical Controversies in Heart Failure and Transplantation. This review contains the summaries of the podium presentations of this session and will cover some of the challenging aspects of caring for these patients including medical and mechanical support, fluid overload states, high-risk populations including those after heart transplantation, and end-of-life considerations.

Biologically-related or emotionally-connected: who would be the better surrogate decision-maker?

As an incapacitated patient is unable to make decisions regarding their care, physicians turn to next-of-kin when appointing a surrogate decision-maker in the absence of an advanced directive. With the increasing complexity of modern families, physicians are facing new ethical dilemmas when choosing the individual to make end-of-life decisions for their patients. Legal definitions and hierarchies are no longer adhering to the purpose of a surrogate-decision maker, which is to maintain a patient's autonomy. Moral criteria for surrogates, which emphasize the importance of making decisions that align with the patient's desires and wishes and negate biological relationships over emotional connections, are becoming much more important. This paper explores a case study in which physicians must appoint a surrogate decision-maker for an incapacitated patient, forced to choose between a biological relationship and a strong emotional connection.

Factors associated with futile end-of-life intensive care in a cancer hospital

BACKGROUND

Management of critically ill patients involves weighing potential benefit of advanced life support against preserving quality of life, avoidance of futile measures and rational use of resources.

AIM

Our study aims to identify the predisposing factors involved in the institution and maintenance of futile intensive care support in terminally ill cancer patients in whom no additional treatment for the malignant disease would be offered.

DESIGN

We retrospectively analysed the medical records of patients who died in a tertiary cancer hospital (Hospital A C Camargo, São Paulo, Brazil) during an eight month period. Medical futility was defined when a patient, despite having been stated in the hospital records as having no possible lifespan extending treatment, was admitted to intensive care and received advanced life support. These cases were compared to controls who received palliative end-of-life care.

RESULTS

Three hundred and forty-seven deaths were recorded, of which 238 did not undergo futile treatment, 71 received full code treatment and 38 received futile treatments. Statistically significant predisposing factors for medical futility were, in our analysis, lack of palliative care team consultation (p < 0.001) and hematologic malignancy (p = 0.036). Qualitative analysis of medical records traced futile treatments to physicians' lacking proactive attitudes in considering prognosis and talking to families.

CONCLUSIONS

We conclude that a significant minority of end-of-life care consists of futile treatments. Strategies to increase Oncologists' and Critical Care specialists' alertness to these issues and expand indications of Palliative Care consultations are recommended.

US health care: the unwinnable war against death

For well over 40 years, the United States has struggled to improve end-of-life care. This effort, heavily focused on living wills, hospice and improved doctor-patient communications and palliative care, has been a modest success only. Both doctors and patients are often unwilling to accept the fact that death is on the way--only 25% of Americans have an advance directive. Advances in medical technology have provided more ways of keeping dying patients alive, making the line between living and dying harder to discern. The way physicians are paid promotes the use of technology not for talking with patients. Underlying these practical problems is a culture of American medicine with deep historical roots: that medical progress should be unending and is a moral imperative, that death is the greatest enemy and that cure, not care, is the primary goal. A better balance between care and cure is needed.

End-of-life care for patients with dementia in the United States: institutional realities

Few are satisfied with end-of-life care in the United States. For families and friends of people with dementia, end-of-life care is particularly frustrating. Providing better end-of-life care to people with dementia is urgent because the prevalence of the disease is increasing rapidly. Dementia is currently the seventh leading cause of death in the United States and fifth leading cause of death among people aged 65 years and older. By 2050, there will be around 19 million people with Alzheimer's disease. This article reviews ethical and policy challenges associated with providing end-of-life care for people with dementia in the United States. I explain how disagreements about the meaning of futility lead to poor care for people with dementia. Most people agree that we should not provide care that is futile, but there is little agreement about how futility should be defined. US policies and politics clearly tip the balance in the direction of treatment, even in the face of strong evidence that such care does more harm than good. Although we may never reach a consensus, it is important to address these questions and think about how to develop policies that respect the different values.

Are the distinctions drawn in the debate about end-of-life decision making "principled"? If not, how much does it matter?

The current ethical-legal consensus - prohibiting assisted suicide and euthanasia, but (1) allowing patients to forgo all life-saving treatment, and (2) permitting pain relief that increases the risk of death - is a means of having it both ways. This is how we often make "tragic choices."

Artificial nutrition and hydration: the evolution of ethics, evidence, and policy

INTRODUCTION

The debate over use of artificial nutrition and hydration (ANH) in terminal illness, including advanced dementia, remains contentious despite extensive ethical and empirical investigation.

METHODS

For this narrative review we undertook a focused, selective review of literature reflecting ethical analysis, empirical assessment of outcomes, legal responses, and thinking within the Roman Catholic religious tradition.

RESULTS

The history of the debate over the past 60 years results from a complex interplay of ethical concerns, a growing empirical database, legal changes, public opinion, and financial as well as institutional concerns. Discussions of ANH today are often conducted without any understanding of this historical context.

DISCUSSION

Patients' interests could be better protected through remedial action at both the individual and the policy levels.

Lost in translation: the unintended consequences of advance directive law on clinical care

BACKGROUND

Advance directive law may compromise the clinical effectiveness of advance directives.

PURPOSE

To identify unintended legal consequences of advance directive law that may prevent patients from communicating end-of-life preferences.

DATA SOURCES

Advance directive legal statutes for all 50 U.S. states and the District of Columbia and English-language searches of LexisNexis, Westlaw, and MEDLINE from 1966 to August 2010.

STUDY SELECTION

Two independent reviewers selected 51 advance directive statutes and 20 articles. Three independent legal reviewers selected 105 legal proceedings.

DATA EXTRACTION

Two reviewers independently assessed data sources and used critical content analysis to determine legal barriers to the clinical effectiveness of advance directives. Disagreements were resolved by consensus.

DATA SYNTHESIS

Legal and content-related barriers included poor readability (that is, laws in all states were written above a 12th-grade reading level), health care agent or surrogate restrictions (for example, 40 states did not include same-sex or domestic partners as default surrogates), and execution requirements needed to make forms legally valid (for example, 35 states did not allow oral advance directives, and 48 states required witness signatures, a notary public, or both). Vulnerable populations most likely to be affected by these barriers included patients with limited literacy, limited English proficiency, or both who cannot read or execute advance directives; same-sex or domestic partners who may be without legally valid and trusted surrogates; and unbefriended, institutionalized, or homeless patients who may be without witnesses and suitable surrogates.

LIMITATION

Only appellate-level legal cases were available, which may have excluded relevant cases.

CONCLUSION

Unintended negative consequences of advance directive legal restrictions may prevent all patients, and particularly vulnerable patients, from making and communicating their end-of-life wishes and having them honored. These restrictions have rendered advance directives less clinically useful. Recommendations include improving readability, allowing oral advance directives, and eliminating witness or notary requirements.

PRIMARY FUNDING SOURCE

U.S. Department of Veterans Affairs and the Pfizer Foundation.

Hospital Policy on Medical Futility — Does it Help in Conflict Resolution and Ensuring Good End-of-Life Care?

Introduction: This paper aimed to ascertain if hospital policy on medical futility helps in conflict resolution, and in ensuring good end-of-life care. Materials and Methods: Literature on the subject published in the last 5 years was identified through Pubmed, and those with empirical data pertaining to the outcomes of interest were examined. A systematic analysis was not possible as papers varied greatly in aims, designs, outcomes and their measures. Instead, the outcomes of representative papers were described and discussed. Results: There is a widespread use of policies and guidelines based on the concept of medical futility. Conflicts are rare and appear to arise primarily from the manner in which policies are implemented. End-of-life care appears to be improving as evidenced by a significant number of deaths occurring following: (i) discussions involving patient, family, healthcare team members; (ii) cessation of intensive care and (iii) cessation of institution of palliative care. Deaths are increasingly taking place in the presence of family and outside the intensive care wards. Finally, post mortem audit of processes and practices indicate (i) compliance but in a limited manner with policies and recommended guidelines, (ii) family satisfaction and (iii) identify areas where improvement in end-of-life (EOL) care can be effected. Key areas are in improving education of, communication with, and documentation by all stakeholders. Conclusion: Hospital policies on medical futility have helped to resolve conflicts and improve end-of-life care. Prospective, multicentre and controlled trials will be useful in determining the value of specific interventions, obtaining generalisable data and facilitating implementation of better end-of-life care models. Key words: Ethics, Palliative care

Perspectives on withdrawing pacemaker and implantable cardioverter-defibrillator therapies at end of life: results of a survey of medical and legal professionals and patients

OBJECTIVE

To determine the opinions of medical professionals, legal professionals, and patients regarding the withdrawal of implantable cardioverter-defibrillator (ICD) and pacemaker therapy at the end of life.

PARTICIPANTS AND METHODS

A survey regarding 5 cases that focused on withdrawal of ICD or pacemaker therapy at the end of life was constructed and sent to 5270 medical professionals, legal professionals, and patients. The survey was administered from March 1, 2008, to March 1, 2009.

RESULTS

Of the 5270 recipients of the survey, 658 (12%) responded. In a terminally ill patient requesting that his ICD be turned off, most legal professionals (90% [63/70]), medical professionals (98% [330/336]), and patients (85% [200/236]) agreed the ICD should be turned off. Most legal professionals (89%), medical professionals (87%), and patients (79%) also considered withdrawal of pacemaker therapy in a non-pacemaker-dependent patient appropriate. However, significantly more legal (81%) than medical professionals (58%; P<.001) or patients (68%, P=.02) agreed with turning off a pacemaker in the pacemaker-dependent patient. A similar number of legal professionals thought turning off a device was legal regardless of whether it was an ICD or pacemaker (45% vs 38%; P=.50). However, medical professionals were more likely to perceive turning off an ICD as legal than turning off a pacemaker (85% vs 41%; P<.001).

CONCLUSION

Most respondents thought device therapy should be withdrawn if the patient requested its withdrawal at the end of life. However, opinions of medical professionals and patients tended to be dependent on the type of device, with turning off ICDs being perceived as more acceptable than turning off pacemakers, whereas legal professionals tended to perceive all devices as similar. Thus, education and discussion regarding managing devices at the end of life are important when having end-of-life discussions and making end-of-life decisions to better understand patients' perceptions and expectations.

Ethical analysis of withdrawing ventricular assist device support

OBJECTIVE

To describe a series of patients with heart failure supported with a ventricular assist device (VAD) who requested (or whose surrogates requested) withdrawal of VAD support and the legal and ethical aspects pertaining to these requests.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of patients at Mayo Clinic, Rochester, MN, from March 1, 2003, through January 31, 2009, who requested (or whose surrogates requested) withdrawal of VAD support and for whom the requests were fulfilled. We then explored the legal and ethical permissibility of carrying out such requests.

RESULTS

The median age of the 14 patients identified (13 men, 1 woman) was 57 years. Requests were made by 2 patients and 12 surrogates. None of the patients' available advance directives mentioned the VAD. For 11 patients, multidisciplinary care conferences were held before withdrawal of VAD support. Only 1 patient had an ethics consultation. All 14 patients died within 1 day of withdrawal of VAD support.

CONCLUSION

Patients have the right to refuse or request the withdrawal of any unwanted treatment, and we argue that this right extends to VAD support. We also argue that the cause of death in these cases is the underlying heart disease, not assisted suicide or euthanasia. Therefore, patients with heart failure supported with VADs or their surrogates may request withdrawal of this treatment. In our view, carrying out such requests is permissible in accordance with the principles that apply to withdrawing other life-sustaining treatments.

How I conduct the family meeting to discuss the limitation of life-sustaining interventions: a recipe for success

The meeting with the family of a hospitalized patient dying with advanced cancer or hematologic disease in which the limitation of life-sustaining interventions is discussed can be a challenge, particularly for junior physicians. A successful conclusion to this discussion involves an outcome in which the family, without coercion or manipulation, comes to accept that the appropriate care has been provided to their loved one, while the caregivers are enabled to provide care that is goal-directed and patient-centered. This type of result can be achieved through an approach in which patient-focused recommendations are offered in the context of diligent efforts to establish and sustain trust, thoughtful preparation, and respectful discussions with the family.

The case of Samuel Golubchuk and the right to live

Samuel Golubchuk was unwittingly at the center of a medical controversy with important ethical ramifications. Mr. Golubchuk, an 84-year-old patient whose precise neurological level of function was open to debate, was being artificially ventilated and fed by a gastrostomy tube prior to his death. According to all reports he was neither brain dead nor in a vegetative state. The physicians directly responsible for his care had requested that they be allowed to remove the patient from life support against the wishes of the patient's family. Concurrently the Manitoba College of Physicians and Surgeons released a statement which states that the final decision to withdraw life support lies with the physician. In our opinion the statement is ethically problematic for a number of reasons. 1. It is an affront to the guiding principles of Western medical ethics: patient autonomy and human freedom. 2. The position of Samuel Golubchuk's physicians and the new statement lack cultural sensitivity towards other traditions. 3. In modern society there exists an erosion of a basic attitude towards the value of life. 4. The ability of physicians to predict life expectancy in terminally ill patients has been shown repeatedly to be quite limited.

Palliative medicine Death Rounds: small group learning on a vital subject

BACKGROUND

The medical student's experience with patients' dying and death has profound impact on personal and professional development. Death Rounds at the University of New Mexico School of Medicine is a small group educational model that promotes student self-reflection, metacognition, professional growth, and collegial support.

OBJECTIVE

To describe the implementation and evaluation activities of a third year clerkship Death Rounds which are a structured, institutionally supported resource for helping students to understand the clinical, ethical, legal, professional, cultural, and spiritual aspects of death.

DESIGN

Medical students attend 2 to 3 small group palliative medicine Death Rounds sessions, facilitated by the attending clerkship director, chief residents, and a palliative care physician.

CONCLUSIONS

The students' assessment of their palliative medicine knowledge and skills in 5 categories before and after participation in Death Rounds rated their skills after Death Rounds higher with effect sizes ranging from 0.9 to 1.9. Evidence from both the Death Rounds Questionnaire and Facilitators' Logs demonstrates that multiple issues and topics were addressed and all associated with the School of Medicine's 6 core competencies. Death Rounds minimally affect on clerkship time and faculty resources.

Intensive care management of the patient with cystic fibrosis

Cystic fibrosis was previously thought to be a disease of childhood. With a better understanding of this condition along with improvements in therapy, patients with cystic fibrosis are now living well into adulthood. The aim of this article is to familiarize the intensive care unit physician with cystic fibrosis care, to discuss complications associated with cystic fibrosis specifically related to the intensive care unit, and to detail the current recommendations for the clinical management of the patient with cystic fibrosis. With advancing disease, the most severely affected organs are the lungs. Obstruction, infection, and inflammation contribute to the decline of pulmonary function, ultimately leading to death. Some patients may be eligible for lung transplantation, but choosing wisely will affect posttransplant survival. Because other organs are affected by the genetic defect and associated treatments, serious complications related to the liver, pancreas, intestines, and kidneys must be considered by the intensivist faced with a patient with cystic fibrosis. As practitioners, the fact that not all patients will survive and help our patients and families gracefully through the end-of-life process should be accepted.

End-of-life care for the hospitalized patient

The majority of Americans die in hospitals where shortcomings in end-of-life care are endemic. Patients often die alone, in pain, their wishes unheeded by physicians. Hospitalists can improve end-of-life care in hospitals dramatically. Hospitalists must relieve symptoms, such as pain, dyspnea, nausea, vomiting, delirium, and depression; communicate clearly; and provide support to patients and families. Hospitalists can increase the number and the timeliness of hospice referrals, allowing more patients to die at home. Finally, physicians must attend to their own sense of grief and loss to avoid burnout and to continue to reap the rewards end-of-life care provides.